The Pill That Still Hasn’t Changed the Politics of Abortion

Anti-abortion advocates at a rally outside the Supreme Court in March.

Photograph by Drew Angerer/Getty

When the abortion drug mifepristone first became legally available in the U.S., in 2000, it seemed to carry with it the potential for a ceasefire in the abortion wars. Because the pills could be administered in a variety of medical settings, and the abortion itself took place at home, the new regimen offered an alternative to the freestanding clinics that had become flashpoints for protest. So-called medical (as opposed to surgical) abortions could occur earlier in gestation, almost as soon as a woman realized that she was pregnant. Americans had fewer moral qualms about abortions performed at this stage, and women preferred to have them then. The drug seemed to unfurl a vision of the future in which abortion was less politicized, more private, and more seamlessly and matter-of-factly folded into health care. In 1999, I wrote a story on the subject, which my editors at the Times Magazine headlined “The Little White Bombshell: This Pill Will Change Everything.” It was hype, but it reflected a mood that was real.

Sixteen years later, it’s clear that the new method did not defuse the abortion debate, let alone change everything. This spring, the Supreme Court will rule on a Texas law that, if upheld, could close most of the state’s abortion clinics. State legislatures have enacted more restrictions on abortion in the past five years than in any other five-year period in the forty-three years since the ruling in Roe v. Wade, according to the Guttmacher Institute. Many of these laws specifically target medical abortion, which now accounts for twenty-three per cent of all such procedures. When I got back in touch with Carole Joffe, a sociologist I’d interviewed back in 1999 about her research on abortion, she said, “It’s the old chess game. The pro-choice side makes a move; they make a counter-move, and on it goes.”

Last week, the F.D.A. announced that it was easing the guidelines for taking mifepristone by lowering the dosage, decreasing the number of visits that a woman must make to a doctor from three to two, and lengthening the period of time, from seven weeks of pregnancy to ten weeks, during which she can obtain the pills. The new guidelines reduce the likelihood of side effects, and reflect “the best evidence-based practice on what is safe and effective,” according to Daniel Grossman, a professor of obstetrics at the University of California, San Francisco, who studies contraception and abortion. “The vast majority of practitioners” have been using this regimen off-label since as early as 2001, Grossman said, rather than using the labelling that the F.D.A. implemented in 2000, which reflected an already outdated protocol that was established in France in the nineteen-eighties. (Doctors regularly prescribe drugs off-label, for many uses.) Three states—Ohio, North Dakota, and Texas—have laws that require doctors to go by the F.D.A. labelling for mifepristone; that denies doctors the discretion they have with other medications to prescribe off-label, but at least they’ll have better instructions to work with now. On Thursday, the Republican governor of Arizona, Doug Ducey, took the extraordinary step of signing a bill that requires doctors in his state to follow the F.D.A. guidelines for mifepristone which were in effect on December 31, 2015, locking in the old F.D.A. labelling and compelling doctors to use an outmoded medical protocol. It’s hard to see anything at work here other than the desire to prevent women from getting abortions.

If mifepristone has not changed the politics of abortion, as pro-choice forces had hoped it would, it has had a practical impact in the lives of many women. Most medical abortions, like their surgical equivalents, continue to take place in specialized clinics. Still, some family practitioners and hospitals that do not provide surgical abortions have “been able to quietly provide medical abortions and remain beneath the radar of opponents,” Joffe said. As anti-choice legislation piles up, the medication has become an important means of insuring access to abortion, particularly for women in certain rural areas, who have in recent years been able to use telemedicine to obtain mifepristone abortions. (Eighteen states now ban that practice, through laws requiring a doctor to be physically present when a woman ingests the first pill.)

Mifepristone remains an overregulated drug, despite the fact that its safety and efficacy records are solid. (A cluster of eight sepsis-related deaths among women who had taken mifepristone in 2006 has not been causally linked to the drug.) The World Health Organization, the American College of Obstetricians, and the American Public Health Association have all recommended training nurse practitioners and physicians’ assistants to provide it, but most states have passed laws stipulating that only physicians can do so. Many doctors who use it in their practice feel that requiring the first dose be taken in a doctor’s presence is unnecessary, and would like to see the drug made available through prescriptions that could be filled at the pharmacy, like other medications.

The new F.D.A. guidelines suggest that it is likely the drug will one day be available in this way. Slow but steady progress, rather than revolutionary transformation, seems to be the prognosis for mifepristone, which continues to attract the hopes of doctors who want to see abortion recognized as a medically straightforward procedure with far fewer encumbrances. Last week, Molly Redden reported in the Guardian on a new pilot study of four clinics—in New York, Hawaii, Washington, and Oregon—that will allow women to receive abortion medication by mail. “It’s the future,” Esther Priegue, the director of counselling at Choices Women’s Medical Center, in Queens, told Redden. “Especially in the times we’re living in today, women experience so many struggles getting through our doors. They’re mothers. They work. Imagine if they could do it all from home, and never have to step into the clinic for even a moment.” This sounds a bit like the hopes of 2000, but for the most part any optimism on the pro-choice side is more tempered now. In this seemingly endless chess game, nobody is underestimating the strategy, or stamina, of the anti-abortion movement.